Heart transplantation: contraindications, complications and ventricular assist devices
THE CONTEXT
Heart transplantation can markedly improve quality of life, but pulmonary vascular resistance and post-transplant complications affect its suitability and outcomes.
Pulmonary vascular disease and transplant choice
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Conventional heart transplantation is contraindicated in pulmonary vascular disease due to long-standing left heart failure, complex congenital heart disease such as Eisenmenger syndrome, and primary pulmonary hypertension.
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High pulmonary vascular resistance may cause the donor right ventricle to fail.
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Heart–lung transplantation can be successful in Eisenmenger syndrome, and lung transplantation has been used for primary pulmonary hypertension.
Rejection
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Episodes of rejection remain common despite routine tacrolimus, mycophenolate mofetil and corticosteroid therapy.
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Rejection may present with heart failure, arrhythmias or subtle electrocardiographic changes.
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Cardiac biopsy is often used to confirm rejection before treatment with high-dose corticosteroids.
Other serious complications
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Progressive atherosclerosis in the donor coronary arteries often causes recurrent heart failure and probably represents chronic rejection.
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Accelerated coronary atherosclerosis is not confined to recipients transplanted for coronary artery disease. Angina is rare because the transplanted heart is denervated.
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Opportunistic infections, including cytomegalovirus and Aspergillus infections, remain a major cause of death in transplant recipients.
Roles of ventricular assist devices
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Ventricular assist devices may provide a bridge to transplantation when donor organs are limited.
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They may provide short-term restoration therapy after a potentially reversible insult such as viral myocarditis.
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They may be used as long-term therapy in some patients when no other options exist.